Abstract
Background
Toothpastes available in Europe contain a range of fluoride concentrations, with some meeting the recommended level for caries prevention (>1000 ppm fluoride (ppm)) and others containing low or no fluoride. This study evaluated toothpaste fluoride concentrations in Latvia and Lithuania to inform targeted public health strategies in regions with a high prevalence of dental caries.
Methods
This cross‐sectional study was conducted from May 2019 to May 2020, using a validated questionnaire in Latvia and Lithuania. Nationally representative samples (1309 families and 5436 members) provided data through a mixed‐mode survey (paper and online) on sociodemographic information, toothpaste type, brand, and type. Descriptive statistics and chi‐square tests (p < 0.05) were used for analysis.
Results
Fifteen percent of families used non‐fluoridated toothpaste and 12% used <1000 part per million (ppm) fluoride. In Latvia, 56.8% of preschoolers and 28.7% of schoolchildren used <1000 ppm or non‐fluoride toothpaste, whereas in Lithuania, 47.2% of preschoolers and 29.1% of schoolchildren used <1000 ppm or non‐fluoride toothpaste; 63% of adolescents and 73% of adults used toothpaste with optimal fluoride content (≥1000 ppm). Of the 228 registered toothpaste types, 62% contained more than 1000 ppm, which is optimal for caries prevention; 29% of Latvian and 24% of Lithuanian families used at least one non‐fluoridated toothpaste.
Conclusion
This study revealed significant gaps in the use of fluoride toothpaste among families in Latvia and Lithuania, especially among children. To effectively prevent dental caries, targeted interventions, and education must promote optimal fluoride toothpaste use, particularly among vulnerable populations.
Keywords: dental caries, dental public health, fluoride, fluoride toothpaste, non‐invasive caries treatment
1. INTRODUCTION
Dental caries, a pathology with significant economic consequences, is prevalent globally, 1 affecting 50% of children worldwide. 2 Europe leads the WHO regions in the prevalence of oral diseases among the WHO regions, affecting 50.1% of adults. This includes the highest rate of dental caries among permanent teeth (33.6%–335 million cases in 2019). 3 Europe also has a high incidence of tooth loss at 25.2% (about 88 million adults), with a prevalence of 12.4%, almost twice the global average. 3 The consumption of high‐sugar substances and inadequate fluoride exposure drive the prevalence of dental caries. 3 The prevention of caries through the regular use of toothpaste with a fluoride concentration between 1000 and 1500 parts per million (ppm) is a well‐established practice for people of all ages. 4 Extensive clinical research over the past six decades has consistently validated the safety and efficacy of fluoride toothpaste, 3 ultimately leading to its inclusion in toothpaste as a recognized essential medicine by the WHO. 4 However, challenges remain owing to public safety concerns and misinformation regarding the benefits of fluoride. 5 Furthermore, fluoride toothpaste in practice varies with availability and affordability issues, particularly in Europe, 6 where regulations do not require minimum fluoride levels, leading to low‐fluoride or non‐fluoride toothpaste options. 7
Notably, data on non‐fluoridated toothpaste use are limited, with significant European policy variations. 8 Given the high prevalence of dental caries in the Baltic region, affecting nearly all adolescents in Latvia, 90% of 4–6‐year‐olds, 70.6% of 12‐year‐olds, 9 and over 75% of 15–18‐year‐olds in Lithuania, 10 , 11 , 12 as well as approximately half of the 7‐8‐year‐olds in Estonia, 13 this study aimed to assess fluoridated and non‐fluoridated toothpaste use in Latvia and Lithuania to understand oral hygiene practices in high‐risk regions and to inform public health interventions and policies.
2. METHODS
A descriptive cross‐sectional study of Latvian and Lithuanian families was conducted using a survey method from May 2019 to May 2020. We followed the Survey Reporting Guidelines (SURGE) (Table S1) when preparing this report. 14 The research protocol is available at https://doi.org/10.17605/OSF.IO/BYXQT
2.1. Ethics
The Latvian protocol was approved by the Ethics Committee of Riga Stradiņš University (No. 6–3/3; September 2018), whereas the Lithuanian protocol was approved by the Kaunas Regional Biomedical Research Ethics Committee (BE‐2‐11, 2020‐03‐03). Following the Declaration of Helsinki 15 and Personal Data Protection Regulation (EUR‐Lex – 32016R0679), the study protocol ensured that parents completed a form that included written informed consent with the option to withdraw anytime. No personal data were tabulated or entered into the analytical phase.
2.2. Research tool
The expert‐developed (IV, IM, JK, and LK) questionnaire assessed toothpaste use across age groups and residential areas. It was initially tested on 10 children (6–14 years) and ten adults, with feedback used for refinement. A subsequent test–retest involving 20 participants confirmed perfect reliability (100%) in identifying toothpaste brands from the provided images, as reported by the teachers. Originally written in Latvian, the questionnaire underwent forward and backward translation into English, and was translated into Lithuanian by Lithuanian experts, with a native English speaker performing back‐translation for accuracy. A pilot study with 25 volunteer parents or caregivers pretested the Lithuanian version.
Data collection included a paper‐based questionnaire in Latvian schools, and an anonymous self‐administered questionnaire via SurveyLegend in Lithuanian schools. Participants provided sociodemographic information (age and family size) and dental information (toothpaste type), including photographs of their brands. In this study, ‘city’ refers to the State cities in Latvia, ‘town’ refers to towns, and ‘rural area’ refers to villages and farmsteads according to the Latvian Law on Administrative Territories and Populated Areas. 16 In Lithuania, according to Law on Republic of Lithuanian territorial administrative units and their boundaries and administrative division of the Republic of Lithuania, ‘city’ refers to the centre of the county, ‘town’ refers to a centre of the municipality and ‘rural area’ refers to villages and farmsteads. 17
2.3. Sample selection
The stratified cluster sampling approach was employed by dividing the population into strata based on the geographic regions within each country. Both public and private schools served as clusters and were selected using a random sampling technique, ensuring a proportional representation according to the size of each stratum. The sampling frame was constructed using a comprehensive list of schools obtained from national education departments. We aimed to recruit approximately 20 children at each selected school, with the final number of participants determined by those who consented to participate. This design considers the clustering effect and ensures a representative sample by incorporating survey weights into the analysis. The sample was selected using stratified cluster sampling, stratified by place of residence (cities, towns, and rural areas) with a margin of error of 0.05 and a confidence level of 95%. Latvia's 2021 data showed approximately 145,990 families with children under 18 years of age, whereas Lithuania's 2011 data showed 239,460 families. 18 To achieve a more accurate representation and account for the estimated 60% use of fluoride toothpaste, the target sample size was set at 385 families per country. 19 , 20 Consequently, approximately 900 families were invited to participate in the study in each country, ensuring a sufficient sample size after accounting for potential nonresponses. This target was met by including at least 20 schools in each country with an average of 20 children per school.
2.4. Survey administration
Survey implementation varied between Latvia and Lithuania. Owing to the COVID‐19 pandemic, it was conducted online in Lithuania and in person by trained interviewers in Latvia. Both methods were consistent with the study objectives and ensured data protection and ethical integrity.
2.4.1. Survey administration in Latvia
Twenty‐five interviewers were trained on ethical principles, study objectives, data protection laws, and effective communication strategies. Letters explaining the study's objectives were sent to the schools and parents. The interviewers worked closely with the school staff to guide the children through the task and record the data on the spot, including the photographs collected by the teachers and entered into the schools by the researchers.
2.4.2. Survey administration in Lithuania
Owing to COVID‐19 restrictions in Lithuania, this study employed a remote methodology. Invitation letters outlining the research objectives and procedures were sent to the principals of the 24 schools. Participation was voluntary and the survey was conducted anonymously using SurveyLegend, a digital platform. Two researchers had access to the raw data and photographs were used without extracting any sensitive details. This approach allowed for safe and ethical data collection while adhering to the pandemic‐related guidelines.
2.5. Data entry and tabulation
Data were collected by interviewers in Latvia and researchers in Lithuania following the data protection guidelines. A customized form was used to gather information from each family member, including country, family code, household size, dwelling type, age, and toothpaste details. In Latvia, teachers requested families to send photographs of their toothpaste tubes and complete the questionnaire. Trained interviewers who followed strict data protection guidelines visited each school and entered the information into a customized research form. The interviewers received these images directly from their parents and coded the information accordingly without involving children or teachers. The coded data gathered information from each family member, including country, family code, household size, dwelling type, age, and toothpaste. In Lithuania, due to COVID‐19 restrictions, investigators cannot visit schools. Instead, schools requested that families send the required information (photographs and questionnaires) directly to the investigators. The researchers collected the data following the same data protection guidelines used in Latvia. The researchers received these images from the families, coded the data, and entered them in the same customized form. One researcher entered the data to ensure accuracy, whereas another checked and validated the entries. In both countries, the data collection process was designed to minimize errors and maintain data privacy. The investigators had access to the same information (the image and questionnaire) and were responsible for data entry.
Toothpaste types were categorized into four groups based on fluoride concentration: non‐fluoridated, <1000 ppm F (suboptimal), 1000–1399 ppm, and 1400–1500 ppm (optimal), according to WHO recommendations 4 and previous research. 21 Respondents were grouped by age as follows: preschoolers (0–5), schoolchildren (6–12), adolescents (13–18), and adults (>18). Datasets from both countries were combined for both analysis and publication. Information on the toothpaste used per family was extracted from photographs taken in Latvia by teachers and in Lithuania by two evaluators. If a toothpaste could not be identified, it was categorized as ‘not available’. All data were considered and no missing data analyses were performed.
2.6. Analysis
The data were cleaned and processed for statistical analysis using R statistical software and the tidyverse and gtsummary packages. 22 , 23 , 24 Descriptive statistics were obtained for the country, age, age group, and area of residence. The chi‐square test was used to compare nominal and ordinal data, with a significance level of 5%.
3. RESULTS
Data were collected from 1309 families including 557 Latvians and 752 Lithuanians. The sample included 5436 family members: 2294 from Latvia and 3142 from Lithuania. The response rates were 62% and 54% for Latvia and Lithuania, respectively. The average family size was four, ranging from 2–12 members in Latvia and 2–15 in Lithuania. A family‐level analysis was conducted. Of the participants, 54% were over 18 years old (52% in Latvia and 55% in Lithuania) and 47% were in cities (50% in Latvia and 45% in Lithuania). The demographic characteristics are presented in Table 1.
TABLE 1.
The demographic characteristics of Latvian and Lithuanian participants.
| Characteristic | Overall, N = 5436 a | Latvia, N = 2294 a | Lithuania, N = 3142 a |
|---|---|---|---|
| Age | 27 (17) | 26 (17) | 28 (17) |
| Age groups | |||
| 0–5 | 364 (6.7%) | 169 (7.4%) | 195 (6.2%) |
| 6–12 | 1248 (23%) | 642 (28%) | 606 (19%) |
| 13–18 | 915 (17%) | 301 (13%) | 614 (20%) |
| >18 | 2909 (54%) | 1182 (52%) | 1727 (55%) |
| Lives In | |||
| City | 2556 (47%) | 1144 (50%) | 1412 (45%) |
| Rural area | 1040 (19%) | 422 (18%) | 618 (20%) |
| Town | 1840 (34%) | 728 (32%) | 1112 (35%) |
Note: Percentages may not be 100% due to rounding.
Mean (SD), n (%).
We found that 15% of individuals used toothpaste without fluoride, 12% used suboptimal toothpaste (<1000 ppm), 13% used toothpaste with 1000–1399 ppm, and 58% used toothpaste with an F concentration ranging from 1400 to 1500 ppm (Table 2).
TABLE 2.
Toothpaste usage in Latvia and Lithuania. A comparison by fluoride concentration (green optimal, yellow suboptimal, red non‐optimal) and toothpaste labeling.
| Characteristic | Overall, N = 5436 a | Latvia, N = 2294 a | Lithuania, N = 3142 a | p‐Value b |
|---|---|---|---|---|
| F concentration in toothpaste | <0.001 | |||
| Not available | 102 (1.9%) | 24 (1.0%) | 78 (2.5%) | |
| No fluoride | 814 (15%) | 322 (14%) | 492 (16%) | |
| <1000 ppm | 674 (12%) | 343 (15%) | 331 (11%) | |
| 1000–1399 ppm | 686 (13%) | 249 (11%) | 437 (14%) | |
| 1400–1500 ppm | 3160 (58%) | 1356 (59%) | 1804 (57%) | |
| Toothpaste type | <0.001 | |||
| Adult toothpaste | 4753 (87%) | 1843 (80%) | 2910 (93%) | |
| Child toothpaste | 683 (13%) | 451 (20%) | 232 (7.4%) |
Note: Percentages may not total 100 due to rounding.
n (%).
Pearson's Chi‐squared test.
Table 3 and Figure S1 show different fluoride toothpaste concentrations used according to age. This shows that toothpaste with <1000 ppm fluoride is mainly used by children under five (34.9% in both countries), whereas non‐fluoridated toothpaste is used by 16.8% of children under five.
TABLE 3.
Fluoride concentration variance in toothpaste by age group in Latvia and Lithuania, in percentages.
| Age group (years) | F toothpaste concentration | ||||
|---|---|---|---|---|---|
| Not available | No fluoride | <1000 ppm | 1000–1399 ppm | 1400–1500 ppm | |
| 0–5 | 2.2 | 16.8 | 34.9 | 15.9 | 30.2 |
| 6–12 | 2.1 | 12.7 | 14.5 | 12.7 | 58.0 |
| 13–18 | 2.0 | 16.2 | 9.2 | 9.6 | 63.0 |
| > 18 | 1.7 | 15.3 | 9.7 | 13.1 | 60.2 |
The details for each country are as follows: preschool children in Latvia and Lithuania were most likely to use toothpaste with a fluoride concentration of <1000 ppm: 42% in Latvia and 28.7% in Lithuania (p < 0.05). In Latvia, 10.7% of schoolchildren used non‐fluoride toothpaste, compared to 14.8% of preschool children, 12.6% of adolescents, and 16.1% of adults. In Lithuania, 61% of adolescents and adults choose toothpaste with >1400 ppm, compared with 34.4% of children aged 0–5 years and 52% of schoolchildren. A similar pattern was observed in Latvia, with a higher use of toothpaste in the optimal fluoride range among adolescents and adults. The results are presented in Table 4 and Figure S2.
TABLE 4.
Differences in fluoride (grouped by 1400–1500 ppm, 1000–1399 ppm, <1000 ppm) and non‐fluoride toothpaste usage by age groups in Latvia and Lithuania.
| F toothpaste concentration | ||||||
|---|---|---|---|---|---|---|
| Age group (years) | Not available | No fluoride | <1000 ppm | 1000–1399 ppm | 1400–1500 ppm | |
| Latvia | 0–5 | 2.4 | 14.8 | 42.0↑ | 15.4 | 25,4↓ |
| 6–12 | 0.9 | 10,7↓ | 14.8 | 9.8 | 63.7 | |
| 13–18 | 1.3 | 12.6 | 11.0 | 8.3 | 66.8 | |
| >18 | 0.8 | 16.1 | 12,2↓ | 11.4 | 59.5 | |
| Lithuania | 0–5 | 2.1 | 18.5 | 28,7↑ | 16.4 | 34.4↓ |
| 6–12 | 3.3 | 14.9 | 14,2↑ | 15.7 | 52.0 | |
| 13–18 | 2.3 | 17.9 | 8.3 | 10.4↓ | 61.1 | |
| >18 | 2.3 | 14.8 | 8.0↓ | 14.2 | 60.6 | |
Note: ↑ Higher than expected (p < 0.01 PearsonChi‐squared test). ↓ Lower than expected (p < 0.01 PearsonChi‐squared test).
In Latvia and Lithuania, 71–73% of urban and rural inhabitants use toothpaste with >1000 ppm, compared to 68% of urban dwellers. Regarding the use of non‐fluoridated toothpaste, there were differences between Latvia and Lithuania regarding their residences. In Latvian cities, fewer people use toothpaste containing 1400–1500 ppm fluoride, opting for non‐fluoridated or <1000 ppm fluoride toothpaste. In contrast, many people in Latvian cities use toothpaste in the 1000–1399 ppm or 1400–1500 ppm range. In Lithuania, the regional differences in toothpaste fluoride concentrations were minimal. The results are presented in Table 5, and the details about the brands are provided in Figure S3.
TABLE 5.
Differences in fluoride (grouped by 1400–1500 ppm, 100–1399 ppm, <1000 ppm) and non‐fluoride toothpaste usage by area of living in Latvia and Lithuania.
| F toothpaste concentration | ||||||
|---|---|---|---|---|---|---|
| Age group (years) | Not available | No fluoride | <1000 ppm | 1000–1399 ppm | 1400–1500 ppm | |
| Latvia | City | 0.4 | 17,7↑ | 18,3↑ | 10.9 | 52.6↓ |
| Rural area | 3,8↑ | 11.8 | 12.8 | 7,6↓ | 64.0 | |
| Town | 0.4 | 9,5↓ | 11.0↓ | 12.6 | 66.5↑ | |
| Lithuania | City | 2.4 | 13.6 | 12.0 | 16,1↑ | 55.8 |
| Rural area | 1.9 | 16.3 | 11.2 | 13.1 | 57.4 | |
| Town | 2.9 | 17.9 | 8,3↓ | 11,6↓ | 59.4 | |
Note: ↑ Higher than expected (p < 0.01 PearsonChi‐squared test). ↓ Lower than expected (p < 0.01 PearsonChi‐squared test).
We identified 113 toothpaste brands in Latvia and 116 in Lithuania, with 375 and 325 subtypes, respectively. In Lithuania, 47% of the brands offered at least one non‐fluoridated toothpaste and 33% were exclusively non‐fluoridated. In Latvia, 41% of brands offered at least one non‐fluoridated variant and 28% were completely non‐fluoridated (Table 6 and Table S2). Among the families, 29% in Latvia and 24% in Lithuania had at least one non‐fluoridated toothpaste, with an average of 26% in both countries. The full raw dataset and results are available at https://doi.org/10.48510/FK2/OF0N9L.
TABLE 6.
Top 25 toothpaste brands used in Latvia and Lithuania and their minimum and maximum fluoride concentration. Percentage totals may vary when multiple choices or votes are allowed per family.
| N families (%) | Toothpastes used in | F Concentration | N families (%) | Toothpastes used in | F Concentration | ||
|---|---|---|---|---|---|---|---|
| Latvia | Min | Max | Lithuania | Min | Max | ||
| 461 (82.8%) | Colgate | 500 | 1500 | 608 (80.9%) | Colgate | 0 | 1500 |
| 316 (56.7%) | Elmex | 500 | 1450 | 452 (60.1%) | Ecodenta | 0 | 1454 |
| 166 (29.8%) | Splat | 0 | 1450 | 192 (25.5%) | Lacalut | 250 | 1482 |
| 120 (21.5%) | Sensodyne | 0 | 1500 | 183 (24.3%) | Sensodyne | 0 | 1450 |
| 116 (20.8%) | Glister | 500 | 950 | 152 (20.2%) | Glister | 500 | 950 |
| 97 (17.4%) | President | 0 | 1450 | 132 (17.6%) | Dentalux | 500 | 1450 |
| 84 (15.1%) | Himalaya | 0 | 1450 | 116 (15.4%) | Elmex | 500 | 1500 |
| 81 (14.5%) | Blend‐a‐med | 1450 | 1450 | 110 (14.6%) | Elgydium | 0 | 1450 |
| 75 (13.5%) | Dentalux | 500 | 1450 | 86 (11.4%) | Blend‐a‐med | 1450 | 1450 |
| 50 (9.0%) | Vademecum | 500 | 1450 | 60 (8.0%) | Parodontax | 0 | 1450 |
| 42 (7.5%) | Aquafresh | 1400 | 1450 | 50 (6.6%) | Aquafresh | 1450 | 1485 |
| 40 (7.2%) | Ecodenta | 0 | 1136 | 48 (6.4%) | Velym | 0 | 1450 |
| 31 (5.6%) | DentaDoc | 500 | 1450 | 45 (6.0%) | Jordan | 1000 | 1450 |
| 30 (5.4%) | Theramed | 1450 | 1450 | 40 (5.3%) | Himalaya | 0 | 1450 |
| 26 (4.7%) | Lacalut | 1360 | 1476 | 30 (4.0%) | Splat | 0 | 1450 |
| 26 (4.7%) | Signal | 500 | 1450 | 25 (3.3%) | Forever Bright | 0 | 0 |
| 25 (4.5%) | Prokudent | 250 | 1450 | 21 (2.8%) | Curasept | 1000 | 1450 |
| 22 (3.9%) | R.O.C.S. | 0 | 900 | 20 (2.7%) | Royal Dent | 0 | 796 |
| 20 (3.6%) | Lesnoj balzam | 0 | 1450 | 19 (2.5%) | Malaleuca | 1450 | 1450 |
| 19 (3.4%) | Elgydium | 0 | 1350 | 19 (2.5%) | Pasta Del Capitano | 0 | 1450 |
| 19 (3.4%) | Parodontax | 0 | 1400 | 17 (2.3%) | Opalescence | 1100 | 1100 |
| 18 (3.2%) | Faberlic | 0 | 1000 | 15 (2.0%) | Lesnoj Balsam | 500 | 500 |
| 17 (3.1%) | Aronal | 1450 | 1450 | 14 (1.9%) | Apacare | 1450 | 1450 |
| 17 (3.1%) | Charcoal | 0 | 1040 | 13 (1.7%) | Faberlic | 0 | 1450 |
4. DISCUSSION
Our study found that only 58% of families in two European countries used fluoridated toothpaste at optimal concentrations (1400–1500 ppm) for high‐risk populations. In contrast, 25% used toothpaste with lower fluoride levels, which lacks the protective effect of higher concentrations 25 and may increase caries risk, defined as active cavitated or non‐cavitated carious lesions among other signs or factors 26 in primary teeth. Young children (1–5 years) are most likely to use low‐fluoride toothpaste, despite evidence of its ineffectiveness since 2009. 27 The European Association of Paediatric Dentistry and the Lithuanian Dental Chamber recommend 1000 ppm F toothpaste for children up to 6 years old and 1450 ppm F for older children. 28 In Latvia, the recommended concentration is 1000–1500 ppm for all ages, with higher concentrations for individuals over six with high caries risk. 29 A ‘dab/rice’ amount of toothpaste is recommended for children under six instead of low‐fluoride toothpaste. 30
It is concerning that 15% of families use non‐fluoridated toothpaste, with the rate in Latvia and Lithuania nearly double that of New Zealand (7%). 31 This discrepancy may be due to differences in public health initiatives, cultural attitudes, and awareness of the benefits of fluoride use. New Zealand actively promotes fluoridation, 32 while varied health policies and personal preferences in the Baltic States 33 may contribute to the increased use of non‐fluoridated toothpaste.
In Japan, 5.1% of parents reported using non‐fluoridated toothpaste for their children, 34 compared to 15% in Latvia and Lithuania. This difference may be due to the cultural perceptions and parental awareness of the role of fluoride in dental health. Increased awareness and targeted health education, as suggested by a Japanese study, may also benefit the Baltic context, where preference for non‐fluoridated toothpaste is relatively high. In Latvia, only 21% of 12‐year‐olds know that their toothpaste contains fluoride, 9 and in Lithuania, fluoride toothpaste use has decreased from 81% to 60% over the past two decades. 35
A study in Brazil found that children of high socioeconomic status were more likely to use toothpaste with no fluoride or less than 1000 ppm F. 36 Similarly, our results showed increased use of non‐fluoridated toothpaste in affluent peripheral urban areas, suggesting a preference for ‘vegan’ or ‘eco‐friendly’ products. Between 33% in Latvia and 47% in Lithuania, households reported using nonfluoridated toothpaste. A study in Australia revealed that 62.6% of children's toothpastes were not fluoridated, with all Australian‐made toothpastes being non‐fluoridated and more expensive options lacking fluoride. 37 This market shift towards non‐fluoridated toothpaste 37 may be driven by lifestyle and environmental values, potentially impacting oral health. Social media also contribute to the spread of false or misleading fluoride content, influencing public perception. 5 Notably, some dental professionals may recommend non‐fluoridated options, 38 highlighting the need for public health messages that integrate environmental and lifestyle choices with the benefits of fluoride in dental care.
Our study did not investigate the reasons for preferring non‐fluoridated toothpaste in Latvia or Lithuania. However, a study in Saudi Arabia found that fluoride toothpaste users better understood its benefits, such as preventing tooth decay and strengthening teeth, than non‐fluoride toothpaste users. 39 Many non‐fluoridated toothpaste users were unaware of the appropriate age to start using fluoride and had misconceptions regarding fluoride toxicity. 39 These findings emphasize the need for educational campaigns to improve fluoride knowledge and encourage accurate dental information from reliable sources.
In contrast, a Japanese study reported that only 5.1% of the children used non‐fluoridated toothpaste, mainly for ‘anti‐gingivitis, halitosis prevention’, and ‘tartar control’. 34 These children also tended to brush less often. 34 The study stressed the importance of educating parents about the role of fluoride toothpaste in preventing dental caries. In addition to the findings from a Japanese study, it is important to note that non‐fluoridated toothpaste can come in various forms, such as eco‐friendly or herbal types. These toothpastes may contain additives, such as charcoal, cinnamon, orange, xylitol, coriander leaves, lime essential oils, tea tree oil, white clay, propolis, strawberry flavour, coconut oil, hemp seed oil, salt, and other natural ingredients that may appeal to individuals seeking vegan or natural products. However, fluoride concentration, regardless of the type, is the most important factor when selecting a toothpaste. To date, no clinical evidence has supported the effectiveness of non‐fluoridated toothpaste in preventing caries. 25 While some vegan toothpastes may not contain fluoride, it is essential to choose a toothpaste with an effective and safe level of fluoride (>1000 ppm for children and >1400 ppm for adults) to ensure proper oral health. 25 None of these additives can replace the therapeutic effect of fluoride.
Affordability has been identified as a barrier to using fluoridated toothpaste. 6 However, in high‐income countries, including Latvia and Lithuania, the lowest‐paid unskilled government worker needs only 0.18–0.21 working days to buy the cheapest fluoridated toothpaste. In general, non‐fluoridated toothpaste is more expensive. Discrepancies in fluoride content and labeling in toothpastes from different countries should be addressed to provide clear information about the efficacy of fluoridated toothpaste. 40 Mandatory fluoride testing is recommended before advertising toothpaste products. In Europe, toothpastes are classified as cosmetics and do not require testing before marketing, posing risks to consumers who may purchase ineffective nonfluoridated toothpastes or products with misleading fluoride levels.
This study has limitations owing to the different data collection methods used in Lithuania and Latvia, which may have resulted in data entry discrepancies. However, consistent results across both countries suggest that potential data transcription errors are unlikely to impact the main findings significantly. Additionally, data categorized as ‘not available’ and derived from photographic evidence represent an inherent limitation in accuracy. Nevertheless, the congruence of the results between the two countries indicates that the impact of these missing data on the overall conclusion is minimal. Even with different survey modalities, both countries' response rates were similar.
Using toothpaste with insufficient fluoride or none may contribute to persistently high caries rates in European countries, 9 , 35 , 41 particularly affecting children more susceptible to caries. This study emphasizes the need for increased public health initiatives and educational campaigns to raise awareness of the importance of adequate fluoride levels in toothpaste, especially for high‐risk caries groups. Efforts should encourage consumer preferences towards toothpastes with fluoride concentrations aligned with the recommendations for effective caries prevention.
5. CONCLUSION
In conclusion, this study highlights the need for targeted public health strategies in Latvia and Lithuania, particularly to promote the optimal use of fluoridated toothpaste among families, especially children. The frequent use of suboptimal fluoride concentrations and the choice of non‐fluoridated toothpaste reveal gaps in public health policy and emphasize the impact of lifestyle choices on dental health. Targeted interventions and education are essential to effectively prevent dental caries in highly prevalent regions. Collaborative efforts between dental health professionals, policymakers, and educators are needed to close the knowledge–behaviour gap regarding fluoridated toothpaste, promote the importance of fluoride, and ultimately improve oral health outcomes in these regions.
6. CLINICAL RELEVANCE
6.1. Scientific rationale for study
Despite fluoride toothpaste's known effectiveness in reducing caries, using non‐fluoride or low‐fluoride toothpaste was a growing concern. This study explores fluoride toothpaste usage in high‐caries countries Latvia and Lithuania, within the European region, which has the highest global caries rates.
6.2. Principal findings
The study found that 40% of young children in Latvia and Lithuania use non‐fluoride (15%) or low‐fluoride toothpaste (25%).
6.3. Practical implications
The study highlights the urgent need for public health campaigns and educational initiatives to promote optimal fluoride toothpaste use, particularly among children, to reduce high caries rates in Latvia and Lithuania.
AUTHOR CONTRIBUTIONS
I.M.: Conceptualization, Data curation, formal analysis, funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Visualization, Writing (original draft) and writing (review and editing). J.N.: Conceptualization, Formal analysis, funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Writing the original draft, and writing, reviewing, and editing. E. Stanceviciene, I.V., L.K., and J.K.: Investigation, Resources, and Writing–review and editing. A.B. and E. Senakola: Funding acquisition, Investigation, Project administration, Resources, Supervision, and Writing, review, and editing. S.E.U.: Data curation, formal analysis, Investigation, Methodology, Software, Supervision, Validation, Visualization, Writing–original draft, and writing–review and editing.
FUNDING INFORMATION
This study was funded in part by a grant from the Latvijas Zinātnes Padome (Latvian Council of Science) under the Fundamental and Applied Research Projects scheme (No. lzp‐2022/1‐0047) entitled ‘Implementation of the Evidence‐Based Pediatric Caries Management Strategies in Latvian Clinical Practice–An Evidence Transfer Study’. In addition, IM acknowledges the financial support from the Postdoc Latvia program (No. 1.1.1.2/VIAA/3/19/543, contract no. 9.‐14.5/27) and the European Regional Development Fund (ERDF). SEU received financial support from the European Union's Horizon 2020 Framework Programme for Research and Innovation (No. 857287). Administrative costs were covered independently. The funders did not have any role in the study design, data collection, analysis, decision to publish, or manuscript preparation.
CONFLICT OF INTEREST STATEMENT
The authors declare no conflict of interest.
Supporting information
Figure S1:
ACKNOWLEDGEMENTS
We express our deepest gratitude to the participating families, teachers, and schools for their invaluable contribution to this study.
Maldupa I, Narbutaite J, Stanceviciene E, et al. Should we be concerned about the use of non‐fluoride toothpaste? A survey study in two European countries. Int J Dent Hygiene. 2025;23:124‐132. doi: 10.1111/idh.12827
Ilze Maldupa and Julija Narbutaite are equal contributors to this work and have been designated as co‐first authors
DATA AVAILABILITY STATEMENT
The original and raw data and analysis scripts supporting the results of this study are available at the Rīga Stradiņš University Institutional Repository Dataverse: https://doi.org/10.48510/FK2/OF0N9L. 42
REFERENCES
- 1. World Health Organization . Global oral health status report: towards universal health coverage for oral health by 2030 [Internet]. WHO; 2022. https://www.who.int/team/noncommunicable‐diseases/global‐status‐report‐on‐oral‐health‐2022 [cited 2022 Nov 18] [Google Scholar]
- 2. Uribe SE, Innes N, Maldupa I. The global prevalence of early childhood caries: a systematic review with meta‐analysis using the WHO diagnostic criteria. Int J Paediatr Dent. 2021;31:817‐830. doi: 10.1111/ipd.12783 [DOI] [PubMed] [Google Scholar]
- 3. WHO . WHO/Europe calls for urgent action on oral disease as highest rates globally are recorded in European region [Internet]. WHO/News/Europe; 2023. https://www.who.int/europe/news/item/20‐04‐2023‐who‐europe‐calls‐for‐urgent‐action‐on‐oral‐disease‐as‐highest‐rates‐globally‐are‐recorded‐in‐european‐region [cited 2023 May 10] [Google Scholar]
- 4. World Health Organization . WHO model list of essential medicines – 22nd list. World Health Organization. 2021. Report No.: WHO/MHP/HPS/EML/2021.02. https://www.who.int/publications/i/item/WHO‐MHP‐HPS‐EML‐2021.02 [cited 2022 Nov 28]
- 5. Lotto M, Sá Menezes T, Zakir Hussain I, et al. Characterization of false or misleading fluoride content on Instagram: Infodemiology study. J Med Internet Res. 2022;24(5):e37519. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6. Gkekas A, Varenne B, Stauf N, Benzian H, Listl S. Affordability of essential medicines: the case of fluoride toothpaste in 78 countries. PLoS One. 2022;17(10):e0275111. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7. ISO . Dentistry — Dentifrices — Requirements, test methods and marking [Internet]. 2017. Report No.: 11609:2017. https://www.iso.org/obp/ui/#iso:std:iso:11609:ed‐3:v1:en
- 8. Arnadóttir IB, Ketley CE, Van Loveren C, et al. A European perspective on fluoride use in seven countries. Community Dent Oral Epidemiol. 2004;32(Suppl 1):69‐73. [DOI] [PubMed] [Google Scholar]
- 9. Maldupa I, Sopule A, Uribe SE, Brinkmane A, Senakola E. Caries prevalence and severity for 12‐year‐old children in Latvia. Int Dent J. 2021;71(3):214‐223. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10. Razmienė J. Oral hygiene condition and dental caries severity in 4‐6 year old children attending pre‐school institutions in Lithuania and relationship between dental caries severity and socioeconomic status of the family: summary of doctoral dissertation: biomedical sciences, odontology (07B) [Internet]. Lietuvos Sveikatos mokslų Universitetas Medicinos Akademija; 2013. https://www.lsmu.lt/cris/handle/20.500.12512/14269 [cited 2023 Jan 19] [Google Scholar]
- 11. Saldūnaitė K. The Evaluation of the Possibilities for Tooth Decay Prevention in Lithuania among 7–12 Year‐Old Schoolchildren [PhD]. Lithuanian University of Health Sciences. 2009.
- 12. Žemaitienė M. Prevalence and Experience of Dental Caries and Analysis of Behavioural and Biological Risk Indicators among Lithuanian Schoolchildren in Late Adolescence [PhD]. Lithuanian University of Health Sciences. 2017.
- 13. Runnel R, Honkala S, Honkala E, et al. Caries experience in the permanent dentition among first‐ and second‐grade schoolchildren in southeastern Estonia. Acta Odontol Scand. 2013;71(3–4):410‐415. [DOI] [PubMed] [Google Scholar]
- 14. Grimshaw J. SURGE (the SUrvey reporting GuidelinE). Guidelines for Reporting Health Research: A User's Manual. John Wiley & Sons, Ltd; 2014:206‐213. [Google Scholar]
- 15. World Medical Association . World medical association declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA. 2013;310(20):2191‐2194. [DOI] [PubMed] [Google Scholar]
- 16. Latvian Law [Internet]. Administratīvo teritoriju un apdzīvoto vietu likums [Law on Administrative Territories and Populated Areas]. 2020. https://likumi.lv/ta/en/en/id/315654 [cited 2023 Dec 21].
- 17. Lithuanian Statistical State Data Agency . Administrative territorial division – Oficialiosios statistikos portalas [Internet]. Administrative Territorial Division. 2018. https://osp.stat.gov.lt/en/regionine‐statistika‐pagal‐statistikos‐sritis [cited 2023 Dec 29]
- 18. Central Statistical Bureau of Latvia. CSB Latvia [Internet] . Total number and average size of private households in regions, cities, municipalities, urban and rural areas at the beginning of year (after administrative‐territorial reform in 2021). 2022. https://stat.gov.lv/en/statistics‐themes/population/private‐households/tables/mvs011‐total‐number‐and‐average‐size‐private [cited 2023 Jan 31]
- 19. Pourhoseingholi MA, Vahedi M, Rahimzadeh M. Sample size calculation in medical studies. Gastroenterol Hepatol Bed Bench. 2013;6(1):14‐17. [PMC free article] [PubMed] [Google Scholar]
- 20. Sergeant ESG . Epitools epidemiological calculators [Internet]. 2018. https://epitools.ausvet.com.au/oneproportion [cited 2023 Jan 31]
- 21. Twetman S, Axelsson S, Dahlgren H, et al. Caries‐preventive effect of fluoride toothpaste: a systematic review. Acta Odontol Scand. 2003;61(6):347‐355. [DOI] [PubMed] [Google Scholar]
- 22. R Core Team . R: A Language and Environment for Statistical Computing [Internet]. R Foundation for Statistical Computing; 2021. https://www.R‐project.org/ [Google Scholar]
- 23. Wickham H, Averick M, Bryan J, et al. Welcome to the Tidyverse. JOSS. 2019;4(43):1686. [Google Scholar]
- 24. Sjoberg DD, Whiting K, Curry M, Lavery JA, Larmarange J. Reproducible summary tables with the gtsummary package. R I Dent J. 2021;13(1):570‐580. [Google Scholar]
- 25. Walsh T, Worthington HV, Glenny AM, Marinho VC, Jeroncic A. Fluoride toothpastes of different concentrations for preventing dental caries. Cochrane Database Syst Rev. 2019;3(3):CD007868. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26. American Academy of Pediatric Dentistry . Caries‐risk assessment and management for infants, children, and adolescents. AAPD; 2023:243‐247 Report No.: 301‐7. [PubMed] [Google Scholar]
- 27. Ellwood RP, Cury JA. How much toothpaste should a child under the age of 6 years use? Eur Arch Paediatr Dent. 2009;10(3):168‐174. [DOI] [PubMed] [Google Scholar]
- 28. Toumba KJ, Twetman S, Splieth C, Parnell C, van Loveren C, Lygidakis NΑ. Guidelines on the use of fluoride for caries prevention in children: an updated EAPD policy document. Eur Arch Paediatr Dent. 2019;20(6):507‐516. [DOI] [PubMed] [Google Scholar]
- 29. Maldupa I, Uribe S, Brinkmane A, Senakola E, Krumina K. Fluorīdu lietošanas vadlīnijas Latvijā [Fluoride Guidelines in Latvia]. Roga Stradins University, Institute of Stomatology; 2014. [Google Scholar]
- 30. Chemical Safety and Health Unit (CHE), WHO . Inadequate or excess fluoride: a major public health concern [Internet]. World Health Organization; 2019. Report No.: WHO/CED/PHE/EPE/19.4.5. https://www.who.int/publications‐detail‐redirect/WHO‐CED‐PHE‐EPE‐19.4.5 [cited 2023 Dec 20] [Google Scholar]
- 31. Hobbs M, Marek L, Clarke R, et al. Investigating the prevalence of non‐fluoride toothpaste use in adults and children using nationally representative data from New Zealand: a cross‐sectional study. Br Dent J. 2020;228(4):269‐276. [DOI] [PubMed] [Google Scholar]
- 32. Guidelines for the use of fluorides [Internet]. Ministry of Health NZ. https://www.health.govt.nz/publication/guidelines‐use‐fluorides [cited 2023 Dec 21]
- 33. Goldman AS, Yee R, Holmgren CJ, Benzian H. Global affordability of fluoride toothpaste. Glob Health. 2008;4(1):7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34. Ota J, Yamamoto T, Ando Y, Aida J, Hirata Y, Arai S. Dental health behavior of parents of children using non‐fluoride toothpaste: a cross‐sectional study. BMC Oral Health 2013. 29;13:74. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35. Stangvaltaite‐Mouhat L, Aleksejūnienė J, Bendinskaite R, et al. The 20‐year trends in caries and associated determinants among adults in “post‐soviet” Lithuania: repeated cross‐sectional studies. Caries Res [Internet]. 2023;57:1‐11. doi: 10.1159/000529021 [DOI] [PubMed] [Google Scholar]
- 36. Lima CV, Pierote JJA, de Santana Neta HA, et al. Caries, toothbrushing habits, and fluoride intake from toothpaste by Brazilian children according to socioeconomic status. Pediatr Dent. 2016;38(4):305‐310. [PubMed] [Google Scholar]
- 37. Smith BD, MacPhail C, Russell J. An assessment of the current status of children's toothpaste in Australia. Aust Dent J. 2021;66(Suppl 1):S56‐S62. [DOI] [PubMed] [Google Scholar]
- 38. Patel MK, Milano M, Messer RL. Acceptance and awareness of southeastern and western private practice pediatric dentists of fluoride‐free toothpastes: a survey study. J Clin Pediatr Dent. 2023;47(5):73‐80. [DOI] [PubMed] [Google Scholar]
- 39. Al‐Zain AO, Fakhry LM, Tallab RA, Natto ZS. Attitude, practice, and knowledge regarding fluoridated toothpaste, brushing, and rinse usage among residents of Jeddah City in Saudi Arabia. Patient Prefer Adherence. 2023;17:23‐39. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40. Benzian H, Holmgren C, Buijs M, van Loveren C, van der Weijden F, van Palenstein HW. Total and free available fluoride in toothpastes in Brunei, Cambodia, Laos, The Netherlands and Suriname. Int Dent J. 2012;62(4):213‐221. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 41. Milciuviene S, Bendoraitiene E, Andruskeviciene V, et al. Dental caries prevalence among 12‐15‐year‐olds in Lithuania between 1983 and 2005. Medicina. 2009;45(1):68‐76. [PubMed] [Google Scholar]
- 42. Maldupa I, Narbutaite J, Stanceviciene E, et al. Use of toothpastes Latvia and Lithuania [Internet]. Dataverse. 2023. doi: 10.48510/FK2/OF0N9L [DOI]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Figure S1:
Data Availability Statement
The original and raw data and analysis scripts supporting the results of this study are available at the Rīga Stradiņš University Institutional Repository Dataverse: https://doi.org/10.48510/FK2/OF0N9L. 42